• renew total body wellness center

    Patient Registration & Health History

    No-Scalpel Vasectomy Procedure

  • Patient Registration

    Please answer the following questions as completely as possible. Answers are not required for every field; if a question is not applicable to you, you may leave that answer field blank.
  •  -
  • Birth Date*
     / /
  • Gender*

  • Work Status*
  • Student Status*
  • Is this visit related to a work injury?*
  •  -

  • Person Responsible for Payment

    Please complete ONLY if NOT the same as patient.
  • Birth Date
     / /
  •  -

  • Financial and Patient Payment Policy

  • Renew Total Body Wellness Center requires a security deposit of $300 to secure your initial appointment with Dr. Rohde. This payment will be applied to any money owed at the time of your visit.

    Please note: we will require payment at the time your appointment is scheduled and confirmed.

    In the event you are a "No Show" or do not give 48 hours notice of cancellation, this fee will be forfeit. If you cancel more than 48 prior to your appointment time, we will refund this reservation fee.

    You can view our full Payment/Financial Policy document at the bottom of this form.

    If you have any questions about this policy, please contact our office at 217-864-2700 or helprenewme@gmail.com.

  • I understand and agree to the terms outlined above.

  • Patient Health History

    Please answer the following questions as completely as possible. Answers are not required for every field; if a question is not applicable to you, you may leave that answer field blank.

  • Medicines

    List all current medication including dosage (ex: 500mg) and frequency (ex: 2x/day). If you are not currently on any medications type "none" in each box.

  • Allergies

    List anything you are allergic to and the reaction to each.

  • Surgeries

    Please include name of surgery and date.

  • Please indicate which, if any, of your blood relatives suffered from any of the following conditions:

  • Conditions:

  • Review of Systems

    Please select any of the following that are positive:
  • General:
  • Eyes:
  • Ear, Nose, Throat:
  • Heart:
  • Respiratory
  • Digestive
  • Urinary
  • Muscles / Joints
  • Skin
  • Neuro
  • Psychology
  • Endocrine
  • Blood
  • Allergic
  • Should be Empty: